Provider Demographics
NPI: | 1508437351 |
---|---|
Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Entity Type: | Organization |
Organization Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Other - Org Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SR DIR PROV ENROLLMENT & ONBOARDING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNIFER |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | JACKSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 615-465-3334 |
Mailing Address - Street 1: | PO BOX 689022 |
Mailing Address - Street 2: | |
Mailing Address - City: | FRANKLIN |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37068-9022 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-465-7211 |
Mailing Address - Fax: | 615-628-6877 |
Practice Address - Street 1: | 1700 E VENICE AVE |
Practice Address - Street 2: | |
Practice Address - City: | VENICE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34292-3190 |
Practice Address - Country: | US |
Practice Address - Phone: | 941-483-7651 |
Practice Address - Fax: | 941-483-7699 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-07-02 |
Last Update Date: | 2022-03-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Single Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Single Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Single Specialty |
No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Single Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Single Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Single Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Single Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Single Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Single Specialty | |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Single Specialty |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Single Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 277033406 | Medicaid |